Before the DSM, there were several different diagnostic systems.

So there was a real need

for a classification that minimized the confusion, created a consensus among the field and
helped mental health professionals communicate using a common diagnostic language.
Published in 1952, DSM-I featured descriptions of 106 disorders, which were referred to as
reactions. The term reactions originated from Adolf Meyer, who had a psychobiological
view that mental disorders represented reactions of the personality to psychological, social
and biological factors (from the DSM-IV-TR).
The term reflected a psychodynamic slant (Sanders, 2010). At the time, American
psychiatrists were adopting the psychodynamic approach.
Heres a description of schizophrenic reactions:
It represents a group of psychotic disorders characterized by fundamental disturbances in
reality relationships and concept formations, with affective, behavioral, and intellectual
disturbances in varying degrees and mixtures. The disorders are marked by strong tendency
to retreat from reality, by emotional disharmony, unpredictable disturbances in stream of
thought, regressive behavior, and in some, a tendency to deterioration.

Disorders also were split into two groups based on causality (Sanders, 2010):
(a) disorders caused by or associated with impairment of brain tissue function and (b)
disorders of psychogenic origin or without clearly defined physical cause or structural
change in the brain. The former grouping was subdivided into acute brain disorders,
chronic brain disorders, and mental deficiency. The latter was subdivided into psychotic
disorders (including affective and schizophrenic reactions), psychophysiologic autonomic
and visceral disorders (psychophysiologic reactions, which appear related to somatization),
psychoneurotic disorders (including anxiety, phobic, obsessivecompulsive, and depressive
reactions), personality disorders (including schizoid personality, antisocial reaction, and
addiction), and transient situational personality disorders (including adjustment reaction and
conduct disturbance).

Oddly enough, as Sanders points out: learning and speech disturbances are categorized
as special symptom reactions under personality disorders.

A Significant Shift
In 1968, the DSM-II came out. It was only slightly different from the first edition. It increased
the number of disorders to 182 and eliminated the term reactions because it implied
causality and referred to psychoanalysis (terms like neuroses and psychophysiologic
disorders remained, though).
When DSM-III was published in 1980, however, there was a major shift from its earlier
editions. DSM-III dropped the psychodynamic perspective in favor of empiricism and
expanded to 494 pages with 265 diagnostic categories. The reason for the big shift?
Not only was psychiatric diagnosis viewed as unclear and unreliable but suspicion and
contempt about psychiatry started brewing in America. Public perception was far from
favorable.
The third edition (which was revised in 1987) leaned more toward German psychiatrist Emil
Kraepelins concepts. Kraepelin believed that biology and genetics played a key role in
mental disorders. He also distinguished between dementia praecoxlater renamed
schizophrenia by Eugen Bleulerand bipolar disorder, which before that were viewed as
the same version of psychosis.
(Learn more about Kraepelin here and here.)
From Sanders (2010):
Kraepelins influence on psychiatry reemerged in the 1960s, about 40 years after his death,
with a small group of psychiatrists at Washington University in St. Louis, MO, who were
dissatisfied with psychodynamically oriented American psychiatry. Eli Robins, Samuel Guze,
and George Winokur, who sought to return psychiatry to its medical roots, were called the
neo-Kraepelinians (Klerman, 1978). They were dissatisfied with the lack of clear diagnoses
and classification, low interrater reliability among psychiatrists, and blurred distinction
between mental health and illness. To address these fundamental concerns and to avoid
speculating on etiology, these psychiatrists advocated descriptive and epidemiological work
in psychiatric diagnosis.
In 1972, John Feighner and his neo-Kraepelinian colleagues published a set of diagnostic
criteria based on a synthesis of research, pointing out that the criteria were not based on
opinion or tradition. In addition, explicit criteria were used to increase reliability (Feighner et

al., 1972). The classifications therein became known as the Feighner criteria. This became
a landmark article, eventually becoming the most cited article pub- lished in a psychiatric
journal (Decker, 2007). Blashfield (1982) suggests that Feighners article was highly
influential, but that the large number of citations (more than 140 per year at that point,
compared with an average of about 2 per year) may have been in part due to a
disproportionate number of citations from within the invisible college of the neoKraepelinians.
The change in the theoretical orientation of American psychiatry toward an empirical
foundation is perhaps best reflected in the third edition of the DSM. Robert Spitzer, Head of
the Task Force on DSM-III, was previously associated with the neo- Kraepelinians, and many
were on the DSM-III Task Force (Decker, 2007), but Spitzer denied being neo- Krapelinian
himself. In fact, Spitzer facetiously resigned from the neo-Kraepelinian college (Spitzer,
1982) on account that he did not subscribe to some of the tenets of the neo-Kraepelinian
credo presented by Klerman (1978). Nevertheless, the DSM-III appeared to adopt a neoKraepelinian standpoint and in the process revolutionized psychiatry in North America.

Its not surprising that the DSM-III looked quite different from earlier versions. It featured the
five axes (e.g., Axis I: disorders such as anxiety disorders, mood disorders and
schizophrenia; Axis II: personality disorders; Axis III: general medical conditions) and new
background information for each disorder, including cultural and gender features, familial
patterns and prevalence.

Heres an excerpt from the DSM-III about manic-depression (bipolar disorder):

Manic-depressive illnesses (Manic-depressive psychoses)
These disorders are marked by severe mood swings and a tendency to
remission and recurrence. Patients may be given this diagnosis in the absence
of a previous history of affective psychosis if there is no obvious precipitating
event. This disorder is divided into three major subtypes: manic type, depressed
type, and circular type.
296.1 Manic-depressive illness, manic type ((Manic-depressive psychosis,
manic type))

This disorder consists exclusively of manic episodes. These episodes are

characterized by excessive elation, irritability, talkativeness, flight of ideas, and
accelerated speech and motor activity. Brief periods of depression sometimes
occur, but they are never true depressive epi- sodes.
296.2 Manic-depressive illness, depressed type ((Manic-depressive
psychosis, depressed type))
This disorder consists exclusively of depressive episodes. These episodes are
characterized by severely depressed mood and by mental and motor
retardation progressing occasionally to stupor. Uneasiness, apprehension,
perplexity and agitation may also be present. When illusions, hallucinations, and
delusions (usually of guilt or of hypochondriacal or paranoid ideas) occur, they
are attributable to the dominant mood disorder. Because it is a primary mood
dis- order, this psychosis differs from the Psychotic depressive reaction, which is
more easily attributable to precipitating stress. Cases in- completely labelled as
psychotic depression should be classified here rather than under Psychotic
depressive reaction.
296.3 Manic-depressive illness, circular type ((Manic-depressive psychosis,
circular type))
This disorder is distinguished by at least one attack of both a depressive
episodeand a manic episode. This phenomenon makes clear why manic and
depressed types are combined into a single category. (In DSM-I these cases
were diagnosed under Manic depressive reaction, other.) The current episode
should be specified and coded as one of the following:
296.33* Manic-depressive illness, circular type, manic*
296.34* Manic-depressive illness, circular type, depressed*
296.8 Other major affective disorder ((Affective psychosis, other))
Major affective disorders for which a more specific diagnosis has not been made
are included here. It is also for mixed manic-depressive illness, in which manic
and depressive symptoms appear almost simultaneously. It does not
includePsychotic depressive reaction (q.v.) or Depressive neurosis (q.v.). (In
DSM-I this category was included under Manic depressive reaction, other.)

(You can check out the entire DSM-III here.)

DSM-IV
Not much changed from DSM-III to DSM-IV. There was another increase in the
number of disorders (over 300), and this time, the committee was more conservative
in their approval process. In order for disorders to be included, they had to have
more empirical research to substantiate the diagnosis.
DSM-IV was revised once, but the disorders remained unchanged. Only the
background information, such as prevalence and familial patterns, was updated to
reflect current research.
DSM-5
The DSM-5 is slated for publication in May 2013 and its going to be quite an
overhaul. Here are posts from Psych Central for more information about the revision:
According the the DSM-5 website, the following changes have been made due to
the comments:
For anorexia nervosa, numerical examples of body weight less than
85% of that expected were replaced simply with markedly low
weight to describe patients physical appearance.
Mechanisms of compensatory behavior for diagnosing bulimia
nervosa were expanded to include medication, excessive exercise,
and fasting.
Wording of one criterion for adjustment disorders was expanded to
include other important areas of functioning.
The Sexual and Gender Identity Disorders Work Group also made revisions to
language involving several disorders within that category:
For all Paraphilia Disorders, two specifiers were added: in
remission and in controlled environment.
Within Pedohebophilic Disorder a new classification that takes in
sexual preference for pubescent children as well as the
prepubescent wording of one criterion was revised to read use of

pornography depicting prepubescent or pubescent children and

another was modified to refer to it.
Hypersexual Disorder was modified to specify that patients must be
at least 18 years old.
Transvestic Disorder now includes the specifier With Autoandrophilia
(Sexually Aroused by Thought or Image of Self as Male) and was
also changed to allow for the possibility of diagnosing females with
this disorder.
Now, of course there will be criticism about this process and whether all 8,600
comments were equally considered or weighted. Im certain they werent. Im also
certain that the fact the workgroups were even able to review all 8,600 comments
and take some of their criticisms into account for the draft of the DSM-5 is
astonishing. I know of no equivalent publisher that has done anything similar in the
field.
Is the process perfect? No, nor will it ever be. By purpose, the current DSM-5
process has had a fundamental difficulty with transparency. Its only been in the past
year where transparency has finally started to occur, based upon many critics
speaking out against the DSM-5 review and editing process.
But I say better late than never. The DSM-5 will be an important edition. Opening
the draft up to review comments was something I recommended back in
December 2009 and while it may be that was always the intention, its good to see
it actually happen.
The DSM-5 is scheduled for publication in May 2013.

References/Further Reading
Sanders, J.L., (2010). A distinct language and a historic pendulum: The evolution of
the diagnostic and statistical manual of mental disorders. Archives of Psychiatric
Nursing, 110.

Grohol, J. (2015). You Do Make a Difference in the DSM-5. Psych Central. Retrieved on September 26, 2015, from
http://psychcentral.com/blog/archives/2010/05/30/you-do-make-a-difference-in-the-dsm-5/